The U.S. birth rate dropped for the second year in a row, down 3% from the prior year, the largest decline since 2010. In 2017, there were nearly 4 million births, 500,000 fewer births than in 2007, even though there has been a 7% increase in women 20 to 39, prime childbearing years, over the past 10 years.

The declines cut across all demographics but are especially evident in women of color. While birth rates in white women over the past 10 years were down 4%, Hispanic women declined 27%, black women 11% and Asian women 5%.

If you look at US health care outcomes, women can hardly be criticized for being cautious. Moms giving birth in the U.S. are three times as likely to die in the process as moms in Canada or the U.K. But that’s not the worst of it. For every woman who does die, 70 more (an estimated 50,000 moms) come close to dying.

There’s a laundry list of contributors – for example pre-eclampsia induced stroke or organ failure, placentas incompletely removed leading to hemorrhage and sepsis, and pulmonary emboli following delivery. These problems are more likely in the uninsured and poor, in those with obesity and diabetes, and in older moms. Women in their 30’s are now having more babies than women in their 20’s.

If a mom is lucky enough to have an uncomplicated birth in the U.S., she is discharged in less than 48 hours and still not completely out of the woods. That’s because post-partum care in America is abysmal. The critical 12 weeks after delivery, which advocates for women’s health have taken to calling the “4th trimester”, traditionally includes one solitary office visit for moms at 6 weeks.

As moms quietly struggle to manage their new infants needs, they end up ignoring their own substantial recovery challenged by perineal and incisional pain, depression and anxiety, bleeding and cramping, chills and night sweats, engorged breasts, constipation, hemorrhoids and more.

If she were in Switzerland, the hospital stay would be longer. In England or France, a midwife would be by in the first week for a home visit. In Sweden or Norway, there’d be a generous maternity leave. (In the U.S., ¼ of women go back to work less than two weeks after birth.)

Maternal care looks bad when numbers are rolled up and averaged. But, as with all other measures in U.S. health care, the geographic, economic and racial disparities are far, far worse. What we tolerate in women’s health care is pitiful.The Affordable Care Act took measures to address this abuse. Prior to the ACA, 1/3 of women attempting to purchase health insurance were either rejected, surcharged with a higher premium, or excluded based on a prior condition. Numbers of uninsured women under 65 climbed from 13% in 2001 to 20% in 2010. For those who were covered, maternity coverage was often missing. ACA outlawed these skinny benefits and exclusions.

By 2016, only 11% of women under 65 remained uninsured, down from 20%. For those uninsured below 200% of the poverty level, the change after ACA was even more striking with uninsured falling from 34% to 18%. In parallel with these changes, all measurers of access to care, from office visits to pharmaceuticals for these vulnerable women have improved.

And yet, the Republican led Congress in lockstep with Trump, stills dreams of “repeal and replace”, and focuses on renewed attacks on women’s health services through defunding of Planned Parenthood.

The “Me-Too” movement is here to stay. There will be no turning back on individual abuse of women. But now is the time to also address broad scale institutional abuse of women as part of the movement. Universal health coverage with a consistent single payer package of meaningful maternal health offerings is an obvious and long overdue response.